Carcinogenic Effects of Areca Nut and Its Metabolites: A Review of the Experimental Evidence

Round 1

Reviewer 1 Report

To summarize and shorten the molecular pathogenesis.

 Add a section on the research related to the attempts to reverse  the changes induced by AN at various molecular, cellular and histological levels

Author Response

Comment 1: To summarize and shorten the molecular pathogenesis.

Response: We considered this request; We feel summarizing and shortening the molecular pathogenesis -which is the main thrust of this study- will limit its educational value.

Comment 2: Add a section on the research related to the attempts to reverse the changes induced by AN at various molecular, cellular, and histological level.

Response: Areca nut intervention studies are extremely limited in literature. Few short-term studies discuss the intervention's success or failure but do not provide data on reversal of tissue changes. Even reversal of any dysplastic changes by histology are not documented. We have therefore not added to this review.

Reviewer 2 Report

Despite being a fairly well written manuscript, focused on the underlying biological mechanisms linking Areca nut and oral carcinogenesis, this paper does not add anything substantially new to the existing body of literature. 

Most of the mechanisms have been previously described and there’s even a recent review on the subject published by Yi-Chen Li et al. (J Cancer 2019; 10: 4054-4062. doi:10.7150/jca.29765).

Moreover, if “novelty” was being considered, it might have been interesting to address the potential impact of Areca nut metabolites on the Oral Microbioma, and how that might impact oral carcinogenesis (e.g. Chen L et al. Molecules. 2022; 27 (23): 8171. doi: 10.3390/molecules27238171, Hernandez BY et al. PLoS One. 2017; 12:e0172196 or Zhong X et al. Oral Dis. 2021; 27: 226-239, etc.)

Overall, the present manuscript fails to add anything new and relevant to the existing body of literature and, hence, does not meet the criteria that might render its publication.

Author Response

Comment 1: Moreover, if “novelty” was being considered, it might have been interesting to address the potential impact of Areca nut metabolites on the Oral Microbioma, and how that might impact oral carcinogenesis.

Response: Thank you so much for the comment. We have now added a section on the effects of areca nut on the oral microbiome, that results in dysbiosis. See: Lines 464-487.  

Reviewer 3 Report

This is nice review about the molecular and carcinogenic effects of Areca nut and its metabolites in the oral mucosa. The authors presented a detailed description about this subject. I have only a minor suggestion. Clinical images with a closer view would be more attractive to the journal readers. This is especially relevant considering the good quality of the other figures in the article.

Author Response

Comment 1: This is nice review about the molecular and carcinogenic effects of Areca nut and its metabolites in the oral mucosa. The authors presented a detailed description about this subject. I have only a minor suggestion. Clinical images with a closer view would be more attractive to the journal readers. This is especially relevant considering the good quality of the other figures in the article.

Response: Thank you so much for this comment. We have now provided better quality clinical images to illustrate various disorders caused by areca nut. See: page 3.  

Reviewer 4 Report

Dear Author,

Greetings

The article is well written and structured, it is relevant to the current context

1.     Carcinogenic effects of Areca nut and its metabolites-A review of the experimental evidence

Dear authors, as the title states that it is a review of experimental evidence, kindly consider whether the type of experiment- invitro/ invivo- the cell culture/ cell lines or animal or computational models or other models were considered; the type of extracts evaluated- aqueous/ acidic/ alcoholic- methanol/ ethanol extracts; the metabolites evaluated; the method of evaluation/ assessment/ the type of assay, brief outcomes/ observations can be tabulated for a prominent no: of studies   

2.     It is mentioned that- Studies based on animal models have revealed that AN extract could be an effective tumour initiator/promoter and may provoke potentially malignant lesions in the oral cavity, such as squamous hyperplasia [15,16], OSF [13,14] or cause malignant transformation [16,28,29]… kindly consider whether the former can be narrated under Areca nut extracts subheading instead

3.     Furthermore, OSF is widespread in the region due to the habitual  chewing of ANs. Kindly be specific

4.     Please check the referencing style

Regards

Author Response

Comment 1: Dear authors, as the title states that it is a review of experimental evidence, kindly consider whether the type of experiment- invitro/ invivo- the cell culture/ cell lines or animal or computational models or other models were considered; the type of extracts evaluated- aqueous/ acidic/ alcoholic- methanol/ ethanol extracts; the metabolites evaluated; the method of evaluation/ assessment/ the type of assay, brief outcomes/ observations can be tabulated for a prominent no: of studies.   

Response: Thank you so much for the comment. We have tabulated the main studies that we have reviewed for clarity.    Table 1 gives the evidence on (1) the nature of extract(s), (2) Type of experiments (3) Analyses conducted and the Main Observations.

Comment 2: It is mentioned that- Studies based on animal models have revealed that AN extract could be an effective tumour initiator/promoter and may provoke potentially malignant lesions in the oral cavity, such as squamous hyperplasia [15,16], OSF [13,14] or cause malignant transformation [16,28,29]… kindly consider whether the former can be narrated under Areca nut extracts subheading instead.

Response: Thank you so much for pointing out this. This is a general statement we made under areca nut extract. As requested, we have now included a modified sentence again under “Effect of Areca nut extracts in molecular carcinogenesis”. See lines 98-100.

Comment 3: Furthermore, OSF is widespread in the region due to the habitual chewing of ANs. Kindly be specific.

Response: This sentence was edited accordingly. See Line 22-24 Oral submucosal fibrosis, a potentially malignant disease of the oral cavity, is predominantly reported from the geographic areas of the globe where AN is habitually chewed.

Comment 4: Please check the referencing style.

Response: Thank you for the comment. The reference style was checked and edited according to the journal guidelines.

Round 2

Reviewer 2 Report

I congratulate the authors for substantially and successfully improving the "Discussion", thus adding to the relevancy of the paper.